ETApplication # / JV
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
MORTGAGE CO. FINANCING COMMERCIAL CHANGE OF OWNERSHIP,
FIRE DAMAGE ETC.
N=. A DEED OR OFFER TD P IR HA cF. IC REOUIRFn a T MfE OF APPLIC.AT7ON
Date: 2L/pi/0-1
Proposed Buyer: M, C44 R'4-- f..
ApplicandMortgage Co: r r1 u o r-fn n rg r•pe.c~,mr> , ~S?gT
Mailing Address: .2c f N~R,~ a c.(t g I-vo
City: s~ts+P~+O State: Zip: 2 133-
Telephone: (9,~ t1 - 141 s -z Fax: (q,a) '1-7; - g 8 s a
Current Land Owner: KP-nnv4 +
riv ly nuuress' d FL, o N o 4 K Cu u Sm~ asp .+c -.-123Z
PIN - Parcel: d ma-70 OK
Name of Subdivision: Lot # if Aphakk)
Daycare: # of employees # of children Hours: tc
There is a $100.00 charge for this service. This approval is subject to revocation U the
intended use of the septic system changes or if false information is provided on this
application.
Your signature below certifies that all above information is
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE US9-ONLY
AUTHORIZATION FOR USE OF EXLS MG SEPTIC SYSTEM
Signature of E ronmental Health Specialist Date
1A14q y 8/07